Provider Demographics
NPI:1144660218
Name:RUSSELL, DIANE MARIE (CMF)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2344 LOCKPORT OLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:NY
Mailing Address - Zip Code:14108-9510
Mailing Address - Country:US
Mailing Address - Phone:716-471-3080
Mailing Address - Fax:
Practice Address - Street 1:2344 LOCKPORT OLCOTT RD
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:NY
Practice Address - Zip Code:14108-9510
Practice Address - Country:US
Practice Address - Phone:716-471-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC49780332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies